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The muscles in the anterior neck can become hypertonic or
develop myofascial trigger points as a result of injury, poor posture, or
simple overexertion. Some anterior cervical muscles are superficial and easily
accessible, while others are deep and difficult to access with soft-tissue
therapies. Because of sensitive neurological and vascular structures in the
neck, it is important to consider these anatomical challenges when treating the
Two primary muscles that lie close to vascular structures in
the anterior neck are the longus colli and longus capitis. Practitioners
applying manual treatments to these deep neck flexors could run the risk of
causing a serious injury to their client, such as stroke or drop in blood
pressure, due to the proximity of the vascular structures.
One of the structures that can be impacted with pressure
from soft-tissue treatment to the anterior neck is the carotid sinus,
which is located at the division between the internal and external carotid
arteries (Figure 1). There is a slight enlargement of the arterial diameter at
this juncture where the two arterial branches separate. A group of very
important sensory cells, called baroreceptors, are also located in the
carotid sinus. The baroreceptors play a primary role in the regulation of blood
pressure and heart rate.
Carotid sinus and muscles in close proximity
In a condition called carotid sinus hypersensitivity
(CSH) or carotid sinus syncope, the carotid sinus develops an
increased sensitivity to pressure. Syncope is a term meaning loss of
consciousness or postural tone caused by a decrease in blood pressure to the
brain. Unintentional pressure on the carotid sinus from massage treatment of
deep anterior neck muscles could cause adverse effects on blood pressure or
heart rate in a person with CSH.
For a person with hypersensitivity in the baroreceptors,
even a mild stimulation to the neck can result in bradycardia (reduced
heart rate) and a drop in blood pressure.1 However, CSH is not common
so clients may not have any problem with pressure applied in this region. For
the few that do have this sensitivity, the consequences of pressure on the
baroreceptors could be serious. Unfortunately, a massage practitioner would not
know if their client had this sensitivity in advance. It is also unlikely that
the client would know they have the condition either. Consequently, it is a bit
of a statistical gamble to perform massage on the deep anterior neck muscles.
There are many practitioners moving away from this type of treatment for safety
There is another concern with pressure applied in the region
of the carotid sinus. In addition to housing the baroreceptors, the shape of
the carotid sinus allows this structure to be a repository for arterial plaque
buildup. Plaque that has collected on the inner walls of the arteries is a
well-known danger. Unintentional pressure applied to the carotid sinus could
dislodge some of these plaque concentrations causing them to migrate through
the arteries and cause a stroke.
Practitioners may think that by avoiding pressing on tissues
with a pulse, they can feel confident that they are not pressing on vascular
structures. However due to the multiple layers of soft-tissues, massage can put
pressure on other nearby structures that subsequently press on the arteries, so
this method is by no means foolproof.
The possibility of adverse affects for anterior neck
treatment should lead the practitioner to explore alternatives in soft-tissue
treatment for the deep anterior cervical muscles. Reducing hypertonicity can be
accomplished by techniques that do not apply direct pressure, such as
facilitated or static stretching. Facilitated stretching can be very effective
in reducing tightness in the deep neck flexors without putting pressure on the
carotid sinus. A position such as that shown in Figure 2 is used for these
facilitated stretching methods.
Position for stretching deep neck flexors
However, the practitioner should be cautious even with
stretching. Ironically, there is a risk of a different arterial compression
with the neck flexor stretching position shown in Figure 2. The vertebral
arteries run through the transverse processes of the cervical vertebrae on each
side of the neck. They join to form the basilar artery, which then extends into
the cranium to supply blood to the brain (Figures 3 & 4).
Side view of vertebral arteries
Mediclip image copyright (1998) Williams & Wilkins.
Figure 4: Posterior view of subocciptal region showing basilar artery Mediclip image copyright (1998) Williams & Wilkins.
When the head is held in hyperextension or rotation (or a
combination of both) the vertebral arteries can be compressed, causing a
reduction in blood flow to the brain.2 Compression of these arteries
is a condition called vertebrobasilar insufficiency (VBI). Symptoms of
VBI include vertigo, dizziness, seeing stars, disorientation, ringing in the
ears, or general feelings of sensory disturbance. If the practitioner is
working in this area or moving the client’s head into rotation or
hyperextension and they report any of these symptoms, treatment should
immediately cease and the client’s head should be brought back to neutral.
The majority of problems with VBI result from hyperextension
or rotation movements of the head. However, due to the location of the
vertebral arteries it is possible that VBI could also occur from common massage
techniques in which pressure is applied to the suboccipital region. While it is
a rare occurrence, some people could have VBI from techniques such as those
depicted in Figure 5, with only the weight of the head applying pressure.
Techniques where pressure is on the occiput and not the suboccipital soft
tissues will not cause VBI. Problems occur when pressure is applied directly
into the suboccipital soft tissues.
Finger pressure in suboccipital region
There is a way to test for the possibility of vertebral
artery compression prior to performing massage techniques. This procedure is
called the vertebral artery test and it is considered an accurate means
of predicting VBI.3 To perform the test, the practitioner has the
client in a seated position and instructs the client to hold their head in
extension or extension with rotation (as if looking over the shoulder). If
within about 30 seconds, the client reports the beginning of VBI symptoms the
practitioner should consider the client susceptible to arterial
compression. Techniques that would put the client in a position that
could aggravate the compression should then be avoided.
Massage is one of the safest interventions for treating
soft-tissue pain and injury conditions in the cervical region. However,
soft-tissue therapy is not benign. As these examples show, there are times when
massage or other soft-tissue therapies could have serious detrimental effects
and that requires the practitioner to think carefully about appropriate
treatments to these sensitive areas.
1. Wijetunga M, Schatz I. Carotid Sinus Hypersensitivity. e-Medicine. 2005. Accessed 3-15-2009.
2. Dabus G, Gerstle RJ, Parsons M, et al. Rotational vertebrobasilar insufficiency due to dynamic compression of the dominant vertebral artery by the thyroid cartilage and occlusion of the contralateral vertebral artery at C1-2 level. J Neuroimaging. Apr 2008;18(2):184-187.
3. Mitchell J, Keene D, Dyson C, Harvey L, Pruvey C, Phillips R. Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? Man Ther. Nov 2004;9(4):220-227.
There is no question about it – kinesiology is cool! That’s what I think anyway, and it boggles my mind when others are not as intrigued. But I think it is just that some simply do not realize the benefit of this fascinating field of study. In many cases knowing kinesiological principles is not just useful, but absolutely essential. Anyone working with pain and injury complaints should have a solid working knowledge of the primary clinical sciences.
Using kinesiology to its full extent is one of the things that will set you apart from other massage therapists and other healthcare professionals. Surprisingly, kinesiology is one of the clinical sciences least understood by soft-tissue practitioners. Many confuse the science of kinesiology with what is called, “applied kinesiology,” which is not really related. More challenging for others is not knowing how to effectively apply these principles in a clinical setting. Yet, kinesiology’s real value is revealed when it fully informs your clinical work.
Sadly, for many this captivating subject got boiled down to mind-numbing memorization of muscle attachment sites and actions in massage school. Notably, it is the passive learning style that predominates in kinesiology education in both basic and continuing education. Read – memorize – take a test. However, if you take a moment to explore the key elements of kinesiology you might just discover a host of valuable ways to incorporate this science in your own clinical work.
What is Kinesiology?
Kinesiology is the exploration of human movement and integrates three disciplines: musculoskeletal anatomy (form), neuromuscular physiology (function), and biomechanics. Kinesiology is that area in which these three disciplines intersect (Figure 1). Having a good foundation in these clinical sciences as they relate to soft-tissue treatment is a great starting point. By default, understanding kinesiological principles returns a better understanding of human structure and function.
Figure 1: Three branches of kinesiology
Your basic education started you out with a solid foundation in muscular anatomy. Soft-tissue therapists should know what the structures are under the skin to which they will be applying soft-tissue treatment. Those working with any level of pain or injuries must know these tissues to have an idea what might be playing a role in their client’s dysfunction.
The clinical knowledge necessary for therapeutic treatment does not stop with muscle names, or with muscle attachment sites. In fact, it should not stop with muscles at all, but should progress to ligaments, tendons, nerve, and fascia – the other soft-tissues often needing to be addressed in various conditions. While muscle tissue is the most common structure massage therapists work with, it is by no means the only cause of soft-tissue pain. If you are not aware of other soft-tissues that may produce pain, you will miss important characteristics of the client’s condition.
While anatomy is the study of structure, physiology is the study of function. The second key element of kinesiology is the function of the locomotor tissues, specifically the neuromuscular connection. Movement occurs because of neurological impulses delivered to muscles causing them to contract. When there is a disruption or irregularity in neuromuscular activity or control, movement disorders and pain can result.
Massage treatments frequently incorporate this fundamental understanding of neuromuscular physiology even though you might not be aware of it. Consider the way in which PNF stretching takes advantage of neuromuscular control principles such as post-isometric relaxation. Other methods such as active isolated stretching rely upon specific positions so as not to initiate the neuromuscular stretch reflex. The client who has postural dysfunction and painful trigger points is treated with methods based on physiological principles of how to best deactivate and neutralize these dysfunctional trigger points.
Biomechanics is the third intersecting clinical science of kinesiology. It is the study of structure and function of biological systems through mechanical physics, basically the study of physical forces. It is sometimes confused with body mechanics, which one learns in applying massage strokes. Performing biomechanical analysis requires an understanding of both anatomy and physiology.
To determine how a structure might respond to various mechanical forces you must be familiar with its physiological characteristics in response to mechanical stress. Evaluating a soft-tissue injury requires exploring the forces applied to the body during injury or activity: their direction, velocity, and intensity. Through this mechanical analysis the practitioner evaluates whether those forces were sufficient to cause specific tissue injuries and consequently how those tissues should be treated.
Putting it Into Practice
As you can see not only is kinesiology a much broader science than you may have realized, but it is an integral part of becoming a highly skilled soft-tissue therapist if you are working with pain and injury complaints. An arsenal of techniques is essentially your bag of tools. However, even with a great bag of tools, if you don’t understand when to use a wrench and when to use a screwdriver and how much force to use when you apply it, your work will be so much less effective.
How to learn more
Understanding kinesiology is exceptionally important when you treat clients having pain and injury complaints. Yet it isn’t easy to find formal coursework in kinesiology that is directly applicable to your massage practice. Most university courses in kinesiology are aimed at physical education professionals and not at manual therapists or healthcare professionals. A continuing education course specifically on kinesiology would ideally integrate the other sciences and clinical reasoning required for application. There are some excellent books available on kinesiology but many people find kinesiology textbooks overwhelming and are not sure how to use the books.
One of the most effective ways to learn kinesiology is through activities that put the information directly into practice and require creative thinking and clinical reasoning by the individual. Choosing CE courses that emphasize kinesiology in conjunction with other clinical sciences as they are applied to various situations is an efficient way to learn these principles. Courses that include problem-based learning, case study evaluations, or scenarios include deeper levels of analysis and allow the individual to immediately apply kinesiology to their coursework.
You can also improve your application of kinesiology by just watching simple movements you see someone performing and analyzing them. Watch someone walking, raking the yard, or working at a checkout stand and analyze what type of forces are being applied to the tissues involved in the activity. When you can apply these principles in the context of your day-to-day work activities, they are much more likely to stick and become meaningful for you.
Massage therapists are ideally positioned to use kinesiology as a valuable and indispensable tool for both assessment and treatment. Putting greater emphasis on applying kinesiology in your practice will pay off with significant rewards of increased treatment success and satisfied clients.
Do you ever recall sitting in a classroom in school and thinking that one or two students were getting the lion’s share of attention when others had things to contribute as well? It seems the world of soft-tissue pain and injury problems shares this metaphor. Take nerve entrapment for example. As soon as you say the phrase upper extremity nerve entrapment, most people’s mind immediately turns toward carpal tunnel syndrome. But there are numerous other nerve compression syndromes that also cause significant pain or dysfunction in the upper extremity.
The long thoracic nerve (LTN) originates from nerve roots at the lower cervical vertebra, usually between C5 and C7. Once the nerve root fibers exit the cervical vertebra, they blend together to form the main trunk of the LTN. The nerve then passes between the anterior and middle scalene muscles immediately adjacent to the other major fibers of the brachial plexus (Image 1).
Image 1: Long thoracic nerve in relation to brachial plexus. Image is from 3D4Medical’s Essential Anatomy 5 application
After passing between the scalene muscles the nerve courses between the clavicle and first rib. It then continues down the lateral aspect of the rib cage to its termination at multiple points along the serratus anterior muscle. The pathway of this nerve is quite long, and consequently there are multiple locations along its path where it is susceptible to compression or traction injury.
The primary function of the LTN is to provide motor innervation to the serratus anterior muscle. The serratus anterior muscle has several key functions. Its major function is to hold the scapula firmly against the thoracic rib cage. Consequently, when there is an interruption of motor stimulus to the serratus anterior, the common pattern of scapular “winging” is present.
The serratus anterior also has another important role and that is upward rotation of the scapula. The movement of upward rotation is a key component of proper scapulothoracic mechanics. Later in this article I will highlight why this role of the serratus anterior is so important and what happens when muscle weakness from nerve impingement affects shoulder biomechanics.
Damage or dysfunction can occur with the LTN from either excessive compression or tension although compression injuries are the most common. There are several locations where compression injuries are likely to occur. Compression could affect LTN roots at the cervical spine from herniated discs, bone spurs, tumors or other obstructions. Moving distally from the nerve root, the next location of potential compression is between the anterior and middle scalene muscles.
The brachial plexus courses between the anterior and middle scalene muscles as this large nerve bundle exits the neck region. The LTN is directly adjacent to the major nerve bundles that comprise the brachial plexus. Often when there is a compression of the brachial plexus, the LTN may also be compressed but symptoms from other nerves of the brachial plexus likely dominate so LTN compression may go undetected.
Other causes of nerve compression in this region include falls or blows directly on top of the shoulder, especially those that may include clavicular fracture.1 Heavy straps such as those in backpacks, knapsacks, shoulder bags, or even bra straps can also compress the nerve. If you are a massage therapist that carries your table around with a strap over your shoulder, this is something to consider.
Rapid tensile loading on the nerve can also cause damage and dysfunction. The rapid stretch of the nerve is most common in sudden lateral flexion movements of the cervical region, such as those that happen in contact sports or in lateral whiplash injuries from automobile accidents.2 There are also some associations of LTN injury with sports activities that have a strong single arm dominance such as bowling, tennis, or golf.
LTN injuries are most frequently associated with some activity. However, nerve compression can also occur from inactivity if the body is in a position that compresses the nerve for long periods. This could happen from awkward sleeping positions or postural strain from a challenging workstation or occupational activity.
There are also reports of LTN injury resulting from surgeries where the patient was placed in a position on the surgical table for hours at a time that caused nerve damage.3 Surgery can also be implicated in LTN damage from direct trauma of the nerve during the surgical procedure. There are reports of LTN injury from mastectomy, first rib resection to treat thoracic outlet syndrome, cardiac surgery, and even spinal fusion surgery to treat scoliosis.4
In addition to the more common causes of nerve injury described above, some anatomical variations can also contribute to LTN pathology. One author described an anatomical anomaly where there was a connecting branch between the dorsal scapular nerve and the long thoracic nerve (Image 2). This connecting branch made each of those nerves less mobile and more likely to cause excess tension throughout the nerve as it is tethered to another structure and not as mobile.5
Image 2: Proximity of long thoracic nerve to dorsal scapular nerve. Image is from 3D4Medical’s Essential Anatomy 5 application
As noted earlier, the LTN is the motor supply nerve for the serratus anterior muscle. The serratus anterior’s function was described as holding the scapula firmly against the thoracic rib cage and also contributing to upward rotation of the scapula. However this function of the serratus anterior should not be oversimplified because it plays a key role in scapulothoracic mechanics.
When the shoulder is moved in abduction there is a coordinated movement between the scapula and humerus called the scapulo-humeral rhythm. This coordinated pattern is described so that for every 3 degrees of abduction, two of them occur at the glenohumeral joint and one at the scapulothoracic articulation. This coordinated movement allows the shoulder to abduct as fully as possible. The upward rotation of the scapula helps make a greater range of motion than would be possible with just glenohumeral abduction alone.
In a situation of LTN compression, weakness of the serratus anterior means that full upward rotation of the scapula does not occur during abduction. Consequently, range of motion in abduction is diminished. However, when the scapula does not move in full upward rotation, the lateral edge of the humeral head is more likely to contact the underside of the acromion process during abduction, leading to shoulder impingement and potential damage to soft tissues in the subacromial region, including the bursa, supraspinatus, or joint capsule.
Symptoms of LTN Pathology:
Because the LTN is primarily a motor nerve, there are not many sensory fibers in the nerve. Consequently, the usual indicators of nerve compression such as sharp pain or paresthesia are not always present, or maybe diminished. Those with LTN injury may report weakness in the shoulder along with pain sensations. Keep in mind that shoulder pain could result from impingement problems that are directly caused by the biomechanical dysfunction. Attempting to address the shoulder impingement and not recognizing the contribution of the LTN involvement could lead to poor results and continual problems.
Sometimes people describe weakness with various shoulder motions. The weakness might be accompanied with pain but could also occur without any pain or sensory deficit. The person may also describe some difficulty performing activities overhead as these motions usually involve a significant degree of scapular upward rotation to complete.
As with any nerve compression or tension injury, the key factor for success is reducing the mechanical load. That means getting pressure off the nerve if it is a compression problem or relieving the excess tensile stress if it is a nerve traction injury. A thorough client history is extremely important in identifying the primary causative factors that may have led to nerve compression or tension injury.
Keep in mind that especially with compression injuries, the longer the force has been applied to the nerve, the slower and longer will be the healing time. Nerve tissue heals very slowly, so it is not unusual for symptom relief to take many months or even a year or longer.6 During the healing process the person should avoid aggravating activities such as carrying heavy loads or continuing to have pressure on the shoulder from heavy straps.
When compression has occurred from external forces such as heavy shoulder straps, removing the offending activity may be sufficient to reduce compression on the nerve. However, in many cases there still may be some soft tissue involvement which can benefit from massage in addressing the primary nerve compression or tension problems. There are a few key areas that are important to address to make sure the nerve has the greatest potential for proper healing.
If LTN compression is occurring between the anterior and middle scalene muscles, it is often hypertonicity or taut bands within these muscles that are compressing the nerve. In those cases the key treatment goal is to reduce muscle tightness so that they do not further compress the nerve. However diving in with deep pressure on these muscles when they may already be tight can be counterproductive and cause more irritation to the nervous system. In many cases a light and gentle pressure on these muscles can be even more effective in helping restore proper tone.
Begin with the client in a supine position. Turn the client’s head slightly to the opposite side and if possible laterally flex their head toward the affected side. This position will slightly shorten the scalene muscles so that there is not as much stretch tension perceived by the muscle. Place the fingertips of one hand near the superior portion of the muscle and the fingertips of the other hand near the inferior ends near the clavicle and first rib (Image 3). Apply a gentle pulling force separating your two hands and hold it for about two minutes.
Image 3: Treatment of scalene muscles to reduce LTN compression
After holding that position, very slowly and gradually let go of the pulling force. By letting go of this force very slowly, it lets the brain adapt to a different sensation coming from the muscles and is more likely to have a longer lasting effect. After pressure is released, take the client’s head and just very slowly and gently move it back and forth in slight flexion and lateral flexion toward the affected side trying to keep from overstretching the muscles that have just been treated. These gentle and easy movement patterns help retrain the neuromuscular pattern perceived by the brain. If you’re not forcibly stretching the muscle, the brain does not have to perceive any potential tissue damage and will not cause as much reactive resistance to the movement.
A similar technique can be applied to the muscles on the top of the shoulder along the path of the long thoracic nerve. Place one hand near the base of the neck and the other hand near the distal end of the clavicle. Slightly laterally flex the client’s head toward the affected side. Apply a traction force to your hands gently pulling them apart and hold this for about two minutes (Image 4). At the end of that period very slowly and gently let go and once again move the neck and shoulder slowly and easily within a comfortable range of motion to help re-encourage safe and pain-free movement.
Image 4: Treatment of shoulder muscles to reduce LTN compression
Sometimes there may be bind and restriction in the lower portions of the long thoracic nerve. These restrictions can be addressed with the client in a side-lying position. Have the client hold one arm across the front of the body and use the other hand to keep the drape in place so the lateral aspect of the rib cage is accessible.
With one or both hands push the surface layer of skin across the lateral rib cage and hold this position for a few moments (Image 5). After holding for a few moments slowly let go and now push in a slightly different direction (more superior or inferior). Pushing and pulling the skin perpendicular to the direction of the nerve will help to mobilize the nerve and make sure it is not being entrapped, bound or restricted by adjacent tissues (Image 6).
When you begin to explore the anatomy of the nervous system it is clear that there are many more locations where nerves are vulnerable to excessive compression or tension than most of us realize. While stories of carpal tunnel, thoracic outlet or nerve root compression dominate most of the focus of nerve compression problems, there is a whole host of other disorders involving other nerve tissues throughout the body. We will explore more of these in future posts.
Keenan KE, Skedros JG. A patient with clavicle fracture and recurrent scapular winging with spontaneous resolutions. Case Rep Orthop. 2012;2012:603726. doi:10.1155/2012/603726.
Oma N, Alvi F, Srinivasan MS. An unusual presentation of whiplash injury: long thoracic and spinal accessory nerve injury. Eur Spine J. 2007;16 Suppl 3:275-277. doi:10.1007/s00586-007-0413-z.
Skedros JG, Phippen CM, Langston TD, Mears CS, Trujillo AL, Miska RM. Complex Scapular Winging following Total Shoulder Arthroplasty in a Patient with Ehlers-Danlos Syndrome. Case Rep Orthop. 2015;2015:680252. doi:10.1155/2015/680252.
Tsirikos AI, Al-Hourani K. Transient long thoracic nerve injury during posterior spinal fusion for adolescent idiopathic scoliosis: A report of two cases. Indian J Orthop. 2013;47(6):621-623. doi:10.4103/0019-5413.121595.
Shilal P, Sarda RK, Chhetri K, Lama P, Tamang BK. Aberrant Dual Origin of the Dorsal Scapular Nerve and Its Communication with Long Thoracic Nerve: An Unusual Variation of the Brachial Plexus. J Clin Diagn Res. 2015;9(6):AD01-AD02. doi:10.7860/JCDR/2015/13620.6027.
Pecina M, Markiewitz A, Krmpotic-Nemanic J. Tunnel Syndromes: Peripheral Nerve Compression Syndromes. Boca Raton: CRC Press; 2001.
Massage is great for many soft-tissue pathologies. However, sometimes various conditions exist that seem like a common pathology, but then don’t respond to the treatment. In some cases an undiscovered problem may exist. In this post we’ll take a look at the synovial plica, a cause of knee pain that can easily mimic other common knee conditions.
What is a plica?
During embryologic development tissues gradually change state as they develop into their fully formed structures. Early in fetal development bands of tissue separate the knee into different compartments. These bands of tissue gradually shrink as the knee joint fully forms and is eventually surrounded by a synovial capsule. However in some people these bands of embryonic tissue persist into adulthood and become sleeves or folds of tissue called synovial folds or plica.1
The medial side of the knee is one of the most common locations for a plica to develop. When it develops in this region, it is called medial plica syndrome and may cause pain and discomfort during various movements and is often mistaken for other knee pathologies.
While the plica will have existed for the person’s entire life, it may become problematic only later as a result of overuse. The plica becomes swollen and fibrotic for several different reasons. The most common reason for plica irritation is chronic overuse. Repetitive motions of the knee cause friction on the plica and it becomes fibrotic and far less flexible. Depending on its location it can become bowstrung across a bony prominence in the knee.
Other possible factors that can lead to a fibrotic plica include a direct blow or trauma to the tissue, excessive twisting motions applied to the knee, or intraarticular bleeding or effusion secondary to another injury. Secondary dysfunction, like meniscal damage, may go undetected or misidentified as some other pathology. In rare cases the plica can become calcified, which causes much greater pain and disrupts tissue mechanics around the knee.2
Once the plica becomes stiff and fibrotic it can get pinched between the femur and patella during knee extension. The medial side of the knee is the most common site prone to irritation of the plica (Figure 1). The medial patellar plica runs underneath the distal portion of the vastus medialis, called the Vastus Medialis Obliquus (VMO). Pain in the VMO is frequently associated with patellar tracking disorders and tracking disorders are another potential issue that can mask involvement of a synovial plica in the region.1
Figure 1 Synovial plica of the knee
The fibrotic changes in the joint can eventually lead to softening and degeneration of the cartilage at the patellofemoral complex. As a result, there may be a cause-effect relationship between the synovial plica and development of chondromalacia patella.1
Evaluating the Plica
Identifying the presence of a synovial plica is not easy because it can be so easily ascribed to some other pathology. However, there are key characteristics that show up when a plica is present. The primary complaint is intermittent dull aching pain medial to the patella. The pain is usually increased with activity and tends to be more evident during forceful knee extension, such as standing up from a squatting position.
Sustained flexion usually increases the pain as the plica tissue is pulled taut. Plica pain generally appears during extension motions, but once the knee is static and held in a position of full extension, such as standing, the pain usually decreases. Additional symptoms may include feelings of giving way, snapping, and popping or clicking sounds especially when moving the knee from 90 degrees of flexion into extension (Figure 2).
Figure 2 Moving the knee from flexion into extension
During palpation it is common to find general tightness in the knee region, especially within the quadriceps group. The fibers of the quadriceps retinaculum are also likely to be tender. There are deep fascial connections between the distal retinacular quadriceps fibers and the synovial capsule of the knee, so reducing quadriceps tightness is a key treatment goal.
One of the more common findings with many knee injuries is atrophy in the quadriceps group and this is common with plica syndrome as well. The quadriceps, as an anti-gravity muscle group, is prone to rapid atrophy when there is pain or dysfunction at the knee. Evaluate quadriceps atrophy by using a soft tape measure to measure the circumference of the muscle group just superior to the patella and comparing it with the unaffected side.
In some cases there is a distinct taut and palpable band on the medial aspect of the knee that can be rolled under the fingers during palpation of the medial knee. It is not always easily palpable, so this method is not a highly reliant means of determining the presence of a plica.
Another method that may be helpful in identifying the plica is a pain provocation test. This can be performed by holding the knee in about 300 of flexion and pushing the patella in a medial direction. Medial movement of the patella reproduces pain as the plica is pinched between the femur and patella.3 Physical examination of the knee alone is not considered highly reliable to identify the plica, so high-tech diagnostic studies such as MRI may be used.
Treatment of Plica
The synovial plica is usually treated first with conservative treatments such as physical therapy, which will include stretching and strengthening exercises. Stretching helps encourage pliability of all the soft tissues. Strengthening of knee extensor fibers is an initial treatment because they have fascial connections into the capsular tissues, which helps pull the plica tissue out of the way during extension and prevent it from being pinched.4 It is also very important for the person to reduce offending activities, such as repetitive flexion and extension movements of the knee.
Nonsteroidial anti-inflammatory drugs (NSAIDS) are commonly used to address inflammatory activity in the knee. Iontophoresis (anti-inflammatory medication applied with electrical stimulation) and phonophoresis (anti-inflammatory medication applied with ultrasound) can also be used to reduce swelling and manage fibrosis. If these more conservative methods are not effective, intraarticular corticosteroid injections might be used. Surgery is considered the last resort to remove plica tissue.
Role of the massage therapist
There is currently no research regarding massage treatment for plica syndrome. However, a lack of study does not indicate a lack of a role for massage. To determine the effectiveness of massage for any pathology requires considering whether some form of massage would provide a helpful intervention.
We do know that massage is effective in reducing dysfunctional soft-tissue fibrosis in many conditions, and plica syndrome is fibrosis that develops within the synovial fold of the knee joint capsule. It would stand to reason that massage might be helpful in addressing medial plica syndrome by encouraging mobility within the fibrotic or calcified plica. If the plica is caught between the femur and patella, you can push the patella slightly laterally and friction the medial side of the tibiofemoral joint and the area just under the patella. You might also provide some deep friction along other regions of the medial side of the knee.
Massage would be generally helpful for maintaining proper muscle tone and biomechanical balance of the VMO and distal quadriceps group so that inappropriate tension levels on the knee capsule fiber do not develop.
A critical part of evaluating the appropriateness of massage is to determine if there might be contraindications. In treating plica syndrome, as long as massage is performed within normal pressure levels, there does not seem to be any contraindications to using massage. In fact, massage is more likely beneficial and might reduce the need for surgical intervention.
Conservative treatments like stretching and exercise have some degree of effectiveness. Massage may be a useful adjunct for these treatments. This syndrome offers a good opportunity for further research into a new application for massage.
Sznajderman T, Smorgick Y, Lindner D, Beer Y, Agar G. Medial plica syndrome. Isr Med Assoc J. 2009;11(1):54-57.
Karaman İ, Güney A, Gürbüz K, Bilal Ö, Güney B. Calcific mediopatellar plica: a case report. Eklem Hast ve cerrahisi = Jt Dis Relat Surg. 2013;24(2):117-120.
Unlike other healthcare fields, such as physical therapy or occupational therapy, massage therapy is actually two primary “tracks.” The first track is geared towards the use of massage as a personal care service, with a focus of general relaxation and wellness enhancement. While massage performed for personal care can enhance health, the focus of this track is not the use of massage as a specific treatment. The second track is the use of massage as a healthcare modality. Massage therapists using massage as a healthcare modality address pain and injury complaints, from the mild to the severe, or other issues of compromised health for an individual.
There currently exist no state licensure credentials that distinguish personal care massage therapists from those using massage as a healthcare modality.
Public safety is the primary issue when evaluating the need for CE. Sometimes the public safety concern is conflated to issues of hygiene or ethics only. However, massage as a pain or injury intervention and treatment modality is anything but benign. When performed inappropriately or for a medical condition where it should not be used, there is clearly the potential for harm to the client. Those working with massage in this capacity must be familiar with the contraindications, assessment and treatment protocols, as well as the cognitive components (anatomy, biomechanics, condition specifics, etc) that function to inform the therapist’s work with their clients. (In addition to the number of other skills that contribute to quality care such as client relations, care and clinical experience).
Right now, for the massage profession it is inappropriate to remove provisions for maintaining licensure that require advancing the education and training of therapists beyond the entry level.
While CE is genuinely debatable for massage therapists working exclusively within the personal care track, it is not for those applying massage as a treatment modality for specific healthcare needs. Without a method for discriminating between the two tracks, CE requirements need to be maintained for the entire massage profession.
Why Continuing Education Must Remain a Requirement
There are many good arguments in favor of continuing education in the massage profession. Below are the primary points that frame the importance of the issue.
CE fills in training gaps in basic education: The minimum requirement for licensure in many states is 500 hours of training. Even in a top-notch 500 hour program, this is nowhere near enough time to prepare an individual for the complexities of clinical practice that are required for advanced therapeutic massage treatment. While many schools are increasing their requirements and trying to prepare their students for the higher expectations of today’s clients, there is no standardization in curricula to meet this particular goal and no state licensures specifically for this type of work.
CE develops clinical competence: It is through the gradual and continual efforts to develop clinical competence that a massage therapist develops their professional skills to a level sufficient to treat clients with musculoskeletal conditions. The Accreditation Council for Graduate Medical Education (ACGME) has noted that clinical competence is not the achievement of a static set of skills. Rather, competence is something developed over time as an individual continually invests in their own self-improvement. The ACGME has described six core competencies that should be developed by medical professionals, which are a very good model for skills a massage therapist in the healthcare environment should aspire to as well. They include: patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal and communication skills, and systems-based practice. 1
CE protects the public: With few exceptions, massage therapists today seek to boost their clientele and practice by taking advantage of the demand for therapeutic massage. If CE is not mandatory many will not choose any training above and beyond their entry-level training. This is simply not adequate for the many complex clinical decisions faced in addressing compromised health conditions. It is through mandatory CE that massage therapists address their knowledge and skill gap so they can practice in a manner that is competent, effective, and safe to the public. Continuing education is currently the graduate program in the massage therapy field.
Currently, the massage profession by default is set up with a built-in reliance on CE. As the massage profession develops and its healthcare track matures, perhaps it will seek accrediting evaluation criteria that emphasize its role as a therapeutic treatment (similar to the programmatic accrediting criteria for physical therapy and occupational therapy). We must also move away from the idea that CE courses have to be about learning a new technique. There are many important aspects of clinical practice that are not taught in entry-level training and are not about learning a new movement with your hands.
There is a strong history in every healthcare profession of continuing education requirements in order to maintain the competence level of practitioners. Massage therapy should be no different.
Resources & Recommended Reading:
Heffron MG, Simspon D, Kochar MS. Competency-based physician education, recertification, and licensure. WMJ : official publication of the State Medical Society of Wisconsin. 2007;106(4):215–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17844712. Accessed September 5, 2012.
Campbell C, Silver I, Sherbino J, Cate OT, Holmboe ES. Competency-based continuing professional development. Medical teacher. 2010;32(8):657–62. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20662577. Accessed August 27, 2011.
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–235. Available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11779266.
Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of continuing medical education. Evidence report/technology assessment. 2007;(149):1–69. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17764217. Accessed September 5, 2012.
O’Neil KM, Addrizzo-Harris DJ. Continuing medical education effect on physician knowledge application and psychomotor skills: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest. 2009;135(3 Suppl):37S–41S. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19265074. Accessed August 3, 2012.
Davis D, O’Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA : the journal of the American Medical Association. 1999;282(9):867–74. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10478694. Accessed September 5, 2012.
Practitioners frequently get asked whether to use heat or cold for soft-tissue pain and injury problems. Of course, the correct answer is always that it depends on the nature of the client’s condition. But what are the key factors upon which heat or cold therapy depends? New research indicates the standard guidelines for hot/cold therapy may need to be reconsidered. In this post we’ll take an in-depth look at cryotherapy and some of the recent controversies around its use.
Cold applications, most commonly known as cryotherapy, involve the application of cold directly to the body for therapeutic purposes. Most frequently, cryotherapy involves applying ice after an acute injury. Ice applications are used to manage and reduce inflammation and reduce pain. However, that long held belief has recently come under scrutiny as a number of authors are suggesting that icing an acute injury may not have the beneficial effects we once thought. Let’s take a look at the key physiological effects of ice applications to better understand their use and if it’s time to reconsider them.
Decreased nerve conduction velocity and pain: Cryotherapy slows the rate at which nerve impulses are propagated along a peripheral nerve. The slowing of this impulse affects both sensory and motor signals in the nerve. One of the most effective uses of cryotherapy, and the reason for its implementation, is the effect it has on reducing pain sensations through decreased nerve conduction velocity. Relieving pain is a good thing, but should be weighed against the other effects produced by the cryotherapy application.
One way that reduced nerve conduction velocity is used in a therapeutic setting is reducing the stretch reflex, also called the myotatic reflex. The stretch reflex is activated by the muscle spindles when they are stretched either too far or too fast (such as in an acute whiplash). Overstretching a hypertonic muscle can also activate the muscle spindles, causing increased muscle tension.
Cryotherapy can decrease the activation of the muscle spindles, which is a benefit for stretching. However, it also decreased the pliability of connective tissue, which is detrimental for stretching. There are times when the neuromuscular resistance to stretching is the key obstacle, such as in an acute muscle spasm. In this case, the neurological benefits of ice outweigh its detriments. One must weigh the benefits of decreased neurological activity vs decreased connective tissue pliability.
Decreased Cellular Metabolism: Cold applications slow down the cellular metabolic activity in the region where the cold is applied. This cellular metabolic reduction has long been hailed as a primary benefit of cold applications, especially in acute injuries. The theory was that it shortens the recovery period from the injury. However, this effect is the factor that clinicians and researchers suggest prolongs the healing process.
The argument goes something like this… Humans have been evolving for millions of years. As part of that evolutionary survival process our bodies have developed an injury response process that involves inflammation following an acute injury. However, in the last several decades we have decided that we need to stop that process because it is detrimental to the healing response of tissues.
It is good to question this stance of whether or not it is beneficial in the healing process to impair the body’s natural healing response. Like all good clinical questions, it should be followed up with research to test the hypothesis. Some initial studies have questioned the therapeutic benefit of reducing inflammation. In one study, treatment comparisons of patients who received ice applications immediately post injury in order to reduce inflammation were compared with those that did not receive ice applications. The ones that did not get ice applications actually fared better. We still need more well-designed studies to investigate this idea, but it does look like it may be time for a paradigm shift.
Decreased Circulation: In response to cold sensations, the smooth muscle cells in the walls of the superficial blood vessels contract and vasoconstrict. Vasoconstriction with cold applications is more pronounced in some regions of the body, such as the distal extremities. The effect of reducing circulation is a physiological effect of ice that may not be desirable.
In addition, tissue healing is enhanced by chemical mediators carried through the blood stream and reducing their movement may interfere with the tissue healing response. Again, this is a physiological response that has developed in the human and mammalian bodies over millions of years, so it seems likely that there would be physiological benefits to these chemical’s circulation and detriments to their limitation.
Edema: Another argument against decreasing circulation is the effect ice has on lymphatic drainage. Edema occurs in the region of a soft-tissue injury after it has occurred. Current thought suggests that excess edema is not beneficial and should be reduced; hence, the use of ice.
However, edema also limits movement in the region and reduces the likelihood of further injury. Edema also increases our sensitivity to pain from pressure on the pain receptors. We generally consider this a bad thing because it hurts, but there is actually a benefit to the increased pain because it helps us limit further movement that could produce greater tissue damage.
Reducing circulation through cold applications also slows down lymphatic drainage and may actually have another detrimental effect on the tissue repair process as a result. Damaged tissue byproducts must be removed from the body and they are removed through the lymphatic system. It may be that cryotherapy for reducing edema could be detrimental in a number of ways.
In Sum: Most therapeutic interventions have positive and negative effects. In each client case we must weigh the potential positive effects against the potential negative effects to evaluate whether it makes physiological sense to pursue a particular approach. These studies may not be enough to alter the way we currently use ice in treatment. However, they should spur us on to pursue additional research in order to find if ice should continue being used like it has or if it is time for a paradigm shift.